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Objective The purpose of this qualitative study is to understand the pregnant and postpartum experiences of Black women in the United States to inform the development of a web-based mobile tool. Methods Participants were recruited through Facebook Groups. There were a total of 19 women that participated in one of five focus group discussions. Participants ranged from being in their 3rd trimester of pregnancy through 6 months postpartum. Thematic content analysis was performed to identify emerging themes. Results Four themes emerged from the focus group discussions: beliefs about postpartum motherhood, experiences during pregnancy, experiences of the postpartum period, and tool recommendations. Key results from these themes demonstrated the difficulties that women faced in having their concerns resolved by healthcare professionals, receiving adequate educational and social support during the COVID-19 pandemic, and having adequate information to help breastfeed and cope with changes they experienced throughout the postpartum period. Conclusion The results highlight the difficulties that Black women experienced throughout pregnancy and the postpartum period. The main findings show that women lacked support in receiving information about the postpartum period, had their concerns dismissed by healthcare professionals, and received inadequate support. These findings can inform the practice of healthcare professionals and inform the development of other non-clinical, digital resources to fill in these gaps. Future research in this area is planned to further develop and pilot the tool among a broader population of women., Author(s): Mariela Rodriguez [sup.1] , Airia S. Papadopoulos [sup.2] , Julia Coleman [sup.3] , Allison Bryant [sup.4] , Kristine Merz [sup.5] [sup.6] , Lisa Marceau [sup.5] [sup.6] [sup.7] Author Affiliations: [...]

Objectives Joyuus is a culturally diverse, comprehensive online tool designed to address the self-care needs of underserved postpartum women. The tool provides actionable self-care information, knowledge, and skills to improve postpartum health and identifies red flags for when self-care shifts to seeking care. Methods We employed a mixed-methods multiphase design to evaluate the Joyuus prototype, including a pre-post evaluation (N = 87) to assess behavioral health outcomes before and after using the tool for a one-month period. 91% completed the post-test (N = 79). The analysis focused on estimation of treatment effect (via 95% confidence intervals) and fitness of instruments in this population. Results Participants were between 6 months pregnant and one year postpartum, a mean age of 30 years, 100% female, 99% Black, with nearly equal distribution of married (55%) and not married (44%), and above (47%) and below (46%) annual income of $60 K. Key measures saw significant improvement from pre- (mean = 26.44, SD = 5.39) to post (mean = 28.29, SD = 5.26) on the Connor-Davidson Resilience Scale (p < 0.001) Trends toward improvement (not statistically significant) were noted for Depression (EPDS) (p = 0.624) and Anxiety (STAI) (p = 0.286), and no meaningful change on MOS Social Support or COVID-19 Mental Health Impacts Measures. Conclusions for Practice This pilot study demonstrates that a self-care mobile tool has the potential to address significant health outcomes related to maternal morbidity and mortality. By providing a continuously available companion addressing physical, mental, and real-life questions, it creates value during postpartum for mothers who can often feel overwhelmed or isolated., Author(s): Allison S. Bryant [sup.1] , Julia Coleman [sup.2] , Xiaomei Shi [sup.3] [sup.4] , Mariela Rodriguez [sup.5] , Airia S. Papadopoulos [sup.3] , Kristine Merz [sup.6] [sup.7] , Juli [...]

Systematic reviews and meta-analyses are essential for drawing conclusions regarding etiologic associations between exposures or interventions and health outcomes. Observational studies comprise a substantive source of the evidence base. One major threat to their validity is residual confounding, which may occur when component studies adjust for different sets of confounders, fail to control for important confounders, or have classification errors resulting in only partial control of measured confounders. We present the confounder matrix--an approach for defining and summarizing adequate confounding control in systematic reviews of observational studies and incorporating this assessment into meta-analyses. First, an expert group reaches consensus regarding the core confounders that should be controlled and the best available method for their measurement. Second, a matrix graphically depicts how each component study accounted for each confounder. Third, the assessment of control adequacy informs quantitative synthesis. We illustrate the approach with studies of the association between short interpregnancy intervals and preterm birth. Our findings suggest that uncontrolled confounding, notably by reproductive history and sociodemographics, resulted in exaggerated estimates. Moreover, no studies adequately controlled for all core confounders, so we suspect residual confounding is present, even among studies with better control. The confounder matrix serves as an extension of previously published methodological guidance for observational research synthesis, enabling transparent reporting of confounding control and directly informing meta-analysis so that conclusions are drawn from the best available evidence. Widespread application could raise awareness about gaps across a body of work and allow for more valid inference with respect to confounder control.

ObjectiveTo evaluate the association of patient preferences and attitudes with TOLAC.Study designProspective observational study of TOLAC-eligible women at 26-34 weeks gestation. Preferences (utilities) were elicited using the time trade-off and standard gamble metrics. Logistic regression was used to identify preference- and attitude-based factors associated with TOLAC.ResultsOf the 231 participants, most (n = 197, 85%) preferred vaginal delivery, but only 40% (n = 93) underwent TOLAC. Utilities for uterine rupture outcomes did not differ based on delivery approach. In multivariable analysis, strength of preference for vaginal delivery, value for the experience of labor, and the opinion of the person whom the participant thought of as most important to this decision were associated with TOLAC.ConclusionsFuture decision support interventions incorporating individualized information regarding the likelihood of vaginal birth and empowering patients to express their preferences and engage their families in the decision-making process may improve decision quality and increase TOLAC rates.

Objective We aimed to examine the relationship of sociodemographic variables with racial/ethnic disparities in unplanned cesarean births in a large academic hospital system. Secondarily, we investigated the relationship of these variables with differences in cesarean delivery indication, cesarean delivery timing, length of second stage and operative delivery. Study Design We conducted a retrospective cohort study of births >34 weeks between 2017 and 2019. Our primary outcome was unplanned cesarean delivery after a trial of labor. Multiple gestations, vaginal birth after cesarean, elective repeat or primary cesarean delivery, and contraindications for vaginal delivery were excluded. Associations between mode of delivery and patient characteristics were assessed using Chi-square, Fisher exact tests, or t -tests. Odds ratios were estimated by multivariate logistic regression. Goodness of fit was assessed with Hosmer Lemeshow test. Results Among 18,946 deliveries, the rate of cesarean delivery was 14.8% overall and 21.3% in nulliparous patients. After adjustment for age, body mass index (BMI), and parity, women of Black and Asian races had significantly increased odds of unplanned cesarean delivery; 1.69 (95% CI: 1.45,1.96) and 1.23 (1.08, 1.40), respectively. Single Hispanic women had adjusted odds of 1.65 (1.08, 2.54). Single women had increased adjusted odds of cesarean delivery of 1.18, (1.05, 1.31). Fetal intolerance was the indication for 39% (613) of cesarean deliveries among White women as compared to 63% (231) of Black women and 49% (71) of Hispanic women (p <0.001). Conclusion Rates of unplanned cesarean delivery were significantly higher in Black and Asian compared to White women, even after adjustment for age, BMI, parity, and zip code income strata, and rates of unplanned cesarean delivery were higher for Hispanic women self-identifying as single. Racial and ethnic differences were seen in cesarean delivery indications and operative vaginal deliveries. Future work is urgently needed to better understand differences in provider care or patient attributes, and potential provider bias, that may contribute to these findings. Key Points Racial, ethnic, and socioeconomic differences exist in the odds of unplanned cesarean. Indications for unplanned cesarean delivery differed significantly among racial and ethnic groups. There may be unmeasured provider level factors which contribute to disparities in cesarean rates. [ABSTRACT FROM AUTHOR]

ObjectiveTo investigate women's understanding of prenatal testing options and of their own experience with screening, diagnostic genetic testing, or both.MethodsThis was a secondary analysis of data from a randomized controlled trial of enhanced information and values clarification regarding prenatal genetic testing in the absence of financial barriers to testing. Women in the third trimester of pregnancy were asked whether they had discussed prenatal genetic testing with their health care providers, whether they understood this testing was optional, and whether they had undergone testing during their pregnancy. Multivariable logistic regression models were fit to determine independent predictors of these outcomes.ResultsData were available from 710 study participants. Discussions about screening tests were reported by 654 participants (92%); only 412 (58%) reported discussing diagnostic testing. That screening and diagnostic testing were optional was evident to approximately two thirds of women (n=470 and 455, respectively). Recall of actual tests undergone was correct for 626 (88%) for screening and for 700 (99%) for diagnostic testing. Racial, ethnic and socioeconomic variation existed in the understanding of whether screening and diagnostic tests were optional and in the correct recall of whether screening had been undertaken in the current pregnancy. In the usual care group, women receiving care in low-income settings were less likely to recall being offered diagnostic testing (adjusted odds ratio 0.23 [0.14-0.39]).ConclusionDisparities exist in women's recall of prenatal genetic testing discussions and their understanding of their own experience. Interventions that explain testing options to women and help clarify their preferences may help to eliminate these differences.

Objectives: Few studies have examined factors associated with compliance with a postpartum visit (PPV). The identification of such factors is of particular importance in populations with high rates of unintended pregnancies and medical complications of pregnancy. This study seeks to determine factors associated with compliance with a PPV among low-income women in the population served by fourteen Healthy Start sites. Methods: Data from the Healthy Start Survey of Postpartum Women were reviewed to identify variables associated with compliance with a PPV at or beyond 6 weeks. Multiple logistic regression models were created, based on a sociobehavioral model of health services use, to examine which types of factors (demographic, social, enabling or need) are most strongly associated with the use of a PPV. Results: The study population consisted of survey respondents interviewed six weeks or more following delivery. Eighty-five percent of respondents had had a PPV at time of interview. In a multiple regression analysis, enabling factors such as multiple moves (OR (95% CI) = 0.34 (0.18, 0.67)), trouble understanding the provider (OR (95 % CI) = 0.65 (0.43, 0.99)) and appointment reminders (OR (95% CI) = 2.37 (1.40, 4.02)) were most strongly associated with a PPV. Conclusions: This work finds that women with unstable housing, transportation barriers, and difficulties communicating with providers are at risk for not receiving a PPV. This suggests that access to postpartum health services in the Healthy Start communities studied may not be entirely equitable. Policies aimed at improving interconception care will need to address these barriers to accessing health services.

Key Points: Question: How does maternal mortality vary by state and race and ethnicity over time in the US? Findings: Long-term trends in maternal mortality ratios from vital registration and census data were estimated. Increases in maternal mortality ratios in specific states were identified and showed previously unmeasured inequities for specific subpopulations. Meaning: Previous research has focused on trends at the national level or in selected states. Comprehensive reporting of disparities in maternal mortality provides evidence to guide intervention policies and benchmark progress for the prevention of maternal deaths. Importance: Evidence suggests that maternal mortality has been increasing in the US. Comprehensive estimates do not exist. Long-term trends in maternal mortality ratios (MMRs) for all states by racial and ethnic groups were estimated. Objective: To quantify trends in MMRs (maternal deaths per 100 000 live births) by state for 5 mutually exclusive racial and ethnic groups using a bayesian extension of the generalized linear model network. Design, Setting, and Participants: Observational study using vital registration and census data from 1999 to 2019 in the US. Pregnant or recently pregnant individuals aged 10 to 54 years were included. Main Outcomes and Measures: MMRs. Results: In 2019, MMRs in most states were higher among American Indian and Alaska Native and Black populations than among Asian, Native Hawaiian, or Other Pacific Islander; Hispanic; and White populations. Between 1999 and 2019, observed median state MMRs increased from 14.0 (IQR, 5.7-23.9) to 49.2 (IQR, 14.4-88.0) among the American Indian and Alaska Native population, 26.7 (IQR, 18.3-32.9) to 55.4 (IQR, 31.6-74.5) among the Black population, 9.6 (IQR, 5.7-12.6) to 20.9 (IQR, 12.1-32.8) among the Asian, Native Hawaiian, or Other Pacific Islander population, 9.6 (IQR, 6.9-11.6) to 19.1 (IQR, 11.6-24.9) among the Hispanic population, and 9.4 (IQR, 7.4-11.4) to 26.3 (IQR, 20.3-33.3) among the White population. In each year between 1999 and 2019, the Black population had the highest median state MMR. The American Indian and Alaska Native population had the largest increases in median state MMRs between 1999 and 2019. Since 1999, the median of state MMRs has increased for all racial and ethnic groups in the US and the American Indian and Alaska Native; Asian, Native Hawaiian, or Other Pacific Islander; and Black populations each observed their highest median state MMRs in 2019. Conclusion and Relevance: While maternal mortality remains unacceptably high among all racial and ethnic groups in the US, American Indian and Alaska Native and Black individuals are at increased risk, particularly in several states where these inequities had not been previously highlighted. Median state MMRs for the American Indian and Alaska Native and Asian, Native Hawaiian, or Other Pacific Islander populations continue to increase, even after the adoption of a pregnancy checkbox on death certificates. Median state MMR for the Black population remains the highest in the US. Comprehensive mortality surveillance for all states via vital registration identifies states and racial and ethnic groups with the greatest potential to improve maternal mortality. Maternal mortality persists as a source of worsening disparities in many US states and prevention efforts during this study period appear to have had a limited impact in addressing this health crisis. This study uses vital registration and census data from 1999 to 2019 to quantify trends in maternal mortality ratios (maternal deaths per 100 000 live births) by state for 5 mutually exclusive racial and ethnic groups in the US using a bayesian extension of the generalized linear model network. [ABSTRACT FROM AUTHOR]

Objectives We sought to determine rates and correlates of accessing health care in the 2 years following delivery among women at an urban academic medical center. Methods We used electronic medical records, discharge, and billing data to determine the occurrence of primary care, other non-primary outpatient care, emergency department visits, and inpatient admissions among women delivering at a single medical center who had a known primary care affiliation to that medical center over a 5 year period. We explored sociodemographic, clinical, and health care-related factors as correlates of care, using bivariate and multivariable modeling. Results Of 6216 women studied, most (91 %) had had at least one health care visit in the window between 2 months and 2 years postpartum (the 'late postpartum period'). The majority (81 %) had had a primary care visit. Factors associated with use of health care in this period included a chronic medical condition diagnosed prior to pregnancy (adjusted odds ratio (AOR) 1.42, 95 % CI [1.19, 1.71]), prenatal care received in an urban community health center (AOR 1.35 [1.06, 1.73]), having received obstetric (AOR 1.90 [1.51, 2.37]), primary (AOR 2.30 [1.68, 3.23]), or other non-primary outpatient care (AOR 2.35 [1.72, 3.39]) in the first 2 months postpartum, and living closer to the hospital [AOR for residence >17.8 miles from the medical center (AOR 0.74 [0.61, 0.90])]. Having had an obstetrical complication did not increase the likelihood of receipt of care during this window. Conclusions for Practice Among women already enrolled in a primary care practice at our medical center, health care utilization in the late postpartum period is high, but not universal. Understanding the characteristics of women who return for health care during this window, and where they are seen, can improve transitions of care across the life course and can provide opportunities for important and consistent interconception and well-woman messaging., Author(s): Allison Bryant[sup.1] , Tiffany Blake-Lamb[sup.1] , Ida Hatoum[sup.2] , Milton Kotelchuck[sup.1] [sup.3] Author Affiliations: (1) Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, 55 Fruit Street, 02114, Boston, [...]

Objective  This study aimed to assess whether a prolonged second stage of labor is an independent predictor of obstetric anal sphincter injury (OASI) in a contemporary cohort of nulliparous and term parturients, and to evaluate whether predelivery factors can accurately predict OASI. Study Design  This was a nested case-control study within a cohort of consecutive nulliparous term parturients with a singleton gestation who underwent a vaginal delivery at a single institution between January 2014 and January 2015. Cases were defined as women with a third- or fourth-degree laceration at the time of delivery, and controls were women without a third- or fourth-degree laceration. A prolonged second stage was defined as a second stage of ≥3 hours. Univariable and multivariable regression analyses were performed to examine the relationship between prolonged second stage of labor and third- or fourth-degree lacerations. Receiver operator curves were developed to assess the predictive capacity of predelivery information for third- and fourth-degree lacerations. Results  Of 1,197 births, 63 women had third- or fourth-degree lacerations (5.3%). With each additional hour of the second stage, the rate of OASI increased, with 2.9% of women with a second stage of <1 hour with OASI, 3.5% between 1 and 2 hours, 5.7% between 2 and 3 hours, 7.8% between 3 and 4 hours, 16.1% between 4 and 5 hours, and 28.6% among women with a second stage length >5 hours (p  < 0.001). In multivariable regression analysis, operative vaginal delivery (adjusted odds ratio [aOR] = 5.92, 95% confidence interval [CI]: 3.17–11.07) and a prolonged second stage (aOR = 1.92, 95% CI: 1.06–3.51) were independent predictors of third- and fourth-degree lacerations. A predictive model was developed from these results (area under the curve [AUC] = 0.75, 95% CI: 0.68–0.81). Conclusion  Prolonged second stage of labor is a predictor of OASI, after adjustment for operative vaginal delivery. A model using predelivery risk factors has a reasonable prediction of OASI. Key Points Prolonged second stage labor is associated with obstetric anal sphincter injury in term nulliparas. Predelivery risk factors reasonably predict obstetric anal sphincter injury in term nulliparas. Improved models are needed for clinical risk-stratification. [ABSTRACT FROM AUTHOR]